Transportation services grapple with statewide brokerage proposal

Belfast — A Maine Department of Health and Human Services initiative to turn the administration of the state's Medicaid-funded transportation systems, currently handled by 10 regional transportation providers around the state, over to a single brokerage is being met with strong skepticism from providers, many of whom believe the change would have a disastrous effect on the state's 30-year-old community action programs.

Officials at Maine DHHS say the change is necessary to comply with a 2009 regulation of the federal Centers for Medicare & Medicaid Services that prohibits transportation providers from also arranging rides. DHHS is also optimistic that switching to a single broker would streamline state transportation services and improve localized complaints about the quality of service available.

Michelle Probert of the Office of MaineCare Services, a division of Maine DHHS, said the agency has been working with CMS for more than a year to come up with a system that would satisfy the new rules. The initial goal, she said, was to keep the regional provider system intact, but the agency's waiver application was denied last November.

In response, DHHS was presented with a list of options, which included several versions of a brokerage system, with potential penalties for noncompliance, Probert said.

The most palatable option, in the view of DHHS, would be a "Risk-Based Prepaid Ambulatory Health Plan,” in which a single broker handles all the administration for the state's Medicaid-reimbursed transportation, and accepts all liability for delivering the service.

The broker would receive a capitated or per person/per month fee to fulfill the federal mandate of providing transportation to all eligible Medicaid recipients.

Probert said the new system is not anticipated to save money for the state, but the intent is to keep administrative costs the same as they are today, while coming in line with federal regulations.

DHHS has largely advocated for the brokerage system in its public documents, painting the change as a simplification of a previously disparate network of providers. But among local providers, who have been offering coordinated transportation services using multiple funding sources for three decades, many see the broker as adding an additional layer of bureaucracy that would make things more difficult for riders.

On a larger level, many worry the loss of the administrative portion of their revenue stream would cause the larger Community Action program to collapse.

Waldo Community Action Partners Executive Director Joyce Scott, who joined WCAP in the late 1970s — the state established regional transportation areas in 1979 — said the accrued knowledge of the regional providers has allowed them to creatively coordinate many funding sources, organize a disparate network of volunteer drivers and other transportation modes, and ultimately offer transportation to a wide range of residents for a minimal cost to taxpayers.

Additionally, regional providers such as WCAP know their constituents, Scott said. They know which drivers are qualified to work with children, which ones are willing to transport patients to methadone clinics and which are physically able to help a wheelchair-bound resident in and out of a vehicle.

"There's a lot of consideration of what we refer to as restraints," she said. "You have to put those pieces together and in the most expedient way. Doing that at the state level ... it's hard to get your head around ... How does a 90-year-old lady describe where she's located? Say if you're at a call center in Connecticut? I can't fathom how it's going to work in the real world."

If brokers don't take these "restraints" into consideration, Scott said she wouldn't be surprised if the region saw a diminished quality of service, or if many of WCAP's 26 volunteer drivers quit. The work is difficult enough as it is, she said.

"It's sad. It's hard. You may have to move someone who may not be ambulatory, who may pass out in your car, throw up in your car, defecate in your car. It's not glamorous but we have people who are very dedicated to what they do."

Medicaid reimbursements make up 85 percent of WCAP's transportation budget, and because that money can be used to leverage matching funds for the nonmedical transportation services, Scott said the loss of the administrative piece would have a disproportionate impact on what services WCAP could continue to provide.

"The administrative piece makes it possible for us to do everything else," she said. "No one else gets paid enough to do what we do."

Piggybacking

As a Full Service Transportation Provider, WCAP gives rides not only to MaineCare recipients, but to elderly people who don't have cars or can't drive, to children, to workers' compensation recipients, and among others, to the general public through its Belfast Shopper circuit in Belfast and regular shuttles to service centers in Bangor, Augusta, Rockland and Waterville.

To do all this, WCAP uses a practice called "piggybacking" in which a single driver transports multiple clients traveling along a similar route.

WCAP Transportation Director Ed Murphy gave the example of a resident on MaineCare who needs a ride to Bangor for a medical appointment. Along that route, the driver may pick up three other people who need to go to Bangor but aren't eligible for MaineCare.

The driver only gets reimbursed for the one rider covered by MaineCare, he said, but because WCAP knows the full range of ride requests, the organization can offer four rides for the price of one by piggybacking.

"[The brokers] won't know where those efficiencies are like the regional providers do," he said.

Murphy went to an April meeting with DHHS officials, at which he said around 35 representatives from regional providers and state agencies attended, but left feeling like the switch to a brokerage system was a done deal.

"We had a chance to say things," he said. "But they had their minds made up."

Part of what has baffled Murphy and representatives of other regional providers, is the speed at which the process has moved and the lack of input sought from providers themselves, many of whom believe there are other options the state should have considered before making the decision to go with a brokerage system.

"It really hasn't made much sense to many of us," said Marcia Larkin, transportation director for Penquis, the Community Action organization that serves Penobscot and Piscataquis counties. "So, we're trying to be diplomatic about it be we would like to have a little more input than we've had."

'The rural exemption'

Under CMS regulations, providers in rural areas can receive a waiver to be both broker and provider because rural areas often have only one eligible transportation provider.

Joyce Scott of WCAP said she could imagine a brokerage working well in an urban area, where the broker could potentially negotiate bulk rates with fixed-route bus services or taxi businesses, but in a rural setting where there is no competition she questioned the value of a broker.

In conversations with other regional providers, the words "rural exemption" invariably came up. As in: why didn't the state seek a rural exemption?

Though Maine is largely rural, five counties — Androscoggin, Cumberland, Penobscot, Sagadahoc and York — are currently classified by CMS as "urban."

Connie Garber, transportation director for York County Community Action Corporation, whose own county would not be eligible for a rural exemption, said the state could have sought rural exemptions for the other 11 counties, then pursued some version of a brokerage for the designated urban counties.

Probert said DHHS reviewed all the regulations with CMS, and called the talk of the rural exemption "a misunderstanding among providers," though she did not indicate whether she was referring only to options that would address the entire state.

In considering the shift to a brokerage, Garber and others have looked to Kentucky, which has managed to both comply with CMS regulations and maintain a regional broker/provider system like the one that exists today in Maine. The difference, Garber said, is that Kentucky switched from a per trip/per mile reimbursement to a capitated system.

"We would be happy with that model but we're told we can't do it," she said. "It would take some learning but it would be a much better option than what's being proposed now."

According to Probert, the state considered several other options in addition to the Risk-Based PAHP, including a Nonrisk PAHP, which she said included the deal-breaking clause that all volunteer drivers register as official providers in order for the state to get full federal reimbursement.

The $6 million question

If the state opted to change nothing, Probert said, DHHS would stand to lose $6 million in federal money, out of a total of $45 million received last year. DHHS literature suggests that retaining the largest federal reimbursement has been a major factor in the decision to go to a brokerage system.

Asked if keeping the system intact and losing the $6 million was an option, Probert reiterated the department's plan is to go with a single statewide broker.

"The department cannot afford $6 million," she said. "The state as a whole may be able to, but it would take a higher level decision if we wanted to shift the money around.”

On the concern raised by Joyce Scott and other regional providers that the broker would be located out of state, Probert said the plan is to require the broker to locate in Maine. As to whom the broker would be, Probert said it would be a competitive bid process, adding that brokers in other states have included private businesses, nonprofit organizations and municipalities.

A foot in the door

Probert said she is aware of the concerns among regional providers that losing the administrative component of their operations would amount to dismantling the longstanding Community Action program, but said the broker would have a strong incentive to keep existing regional transportation providers in business.

“We and any broker out there don’t want the current provider system to go under because then members aren’t getting the rides they need,” she said.

To that end, Probert said the Request For Proposals will ask bidders for ideas about how to continue coordinated services.

What that ultimately means is unclear. Joyce Scott of WCAP, speaking in April, said she was concerned that brokers would get a foot in the door through the current nonemergency medical transportation initiative then expand to other areas, encroaching further on the role of regional providers.

Probert seemed to confirm Scott's suspicions, saying the state is looking at the possibility of using a broker for transportation reimbursed through other state agencies in the future.

Under the current time line, DHHS would issue the RFP in June, award the contract in fall 2011 and aim to have the new system in place by winter 2012.

Probert attributed the fast pace to pressure from CMS. But regional providers expressed a desire to slow the process and get more input from the providers themselves.

"Who do they think the experts are if it's not the people who are doing it every day," said Joyce Scott of WCAP.

Probert said DHHS is still drafting the RFP. “A lot of the details are not set in stone,” she said, noting the agency is holding a MaineCare member focus group in late May.

For their part, the providers are feeling left out, and to a certain extent, left in the dust.

"I absolutely understand that the focus for MaineCare is to be in compliance with federal regulations," said Connie Garber of YCCAC. "Our contention is that there have been opportunities that they have not been willing to look at."